Claims Regulatory and Medicare Senior Specialist

Pie's mission is to empower small businesses to thrive by making commercial insurance affordable and as easy as pie. We leverage technology to transform how small businesses buy and experience commercial insurance.   Like our small business customers, we are a diverse team of builders, dreamers, and entrepreneurs who are driven by core values and operating principles that guide every decision we make.

The  Claims Regulatory and Medicare Senior Specialist for Workers' Compensation and Commercial Auto is responsible for overseeing compliance with state and federal regulations related to Workers' Compensation and Commercial Auto claims adjudication.  This role involves analyzing claims data, ensuring adherence to regulatory standards, filing all relevant data calls required for all states as well as collaborating with various departments to enhance operational efficiency and regulatory compliance. The claims regulatory compliance role is essential to navigate the complex landscape of regulations while ensuring protection to minimize risks, and promoting operational excellence within the claims management process.

How You’ll Do It

Regulatory Compliance:

• Monitor and interpret state and federal regulations governing Workers' Compensation and Commercial Auto Claims.   Procedures must comply with applicable laws and regulatory requirements.
• Prepare, document, analyze for accuracy and communicate responses to all regulatory reporting agencies.
• Conduct comprehensive research on relevant laws, regulations and industry best practices to inform compliance strategies.

Medicare Compliance:

• Ensure compliance with Medicare Secondary Payer (MSP) regulations and guidelines related to workers' compensation and commercial auto claims.  This involves staying up-to-date with Medicare regulations and guidelines and implementing them into the claims handling process.
• Communicate and coordinate with the Centers for Medicare and Medicaid Services (CMS),  Medicare Administrative Contractors (MAC) and Section 111 to report and resolve Medicare-related issues and inquiries.
• Review workers' compensation and commercial auto claims to identify potential Medicare beneficiaries and assess the need for Medicare reporting and compliance.  Analyzing claim details, medical records, and treatment plans to assist the claims team in determining the primary payer responsibility.
• Generate and submit required reports and documentation to Medicare and other relevant authorities.  This may include reporting claims information, tracking payments made, and ensuring accurate and timely report of any changes or updates to claim status.

Data Analysis:

• Analyze workers' compensation and commercial auto claims data to identify trends, compliance issues, and opportunities for improvement.
• Prepare detailed reports for management, highlighting regulatory compliance status and recommending actionable solutions.

Compliance Audits and Investigation:

• Develop, implement and update policies and procedures related to workers' compensation and commercial auto claims to reflect regulatory changes.
• Working collaboratively with Pie's legal counsel and other stakeholders in executing all responsibilities and in supporting and advancing compliance.
• Collaboration with our Claims Learning & Development team to drive continuing education on compliance related issues
• Develop compliance reporting best practices and drive action plans for improvement based off leading indicators and evidence-based findings.

 

The Right Stuff

• Bachelor's Degree is required. AIC, ARM, CWCP are preferred.
• 10 years of industry experience within a carrier or TPA insurance environment with expertise in workers' compensation and commercial auto regulatory filings and Medicare regulations. Understanding and practical application of complex regulations within the casualty insurance environment.               
• 8 years of prior experience in conducting audits, assessments or investigations in a compliance capacity for casualty claims.
• 5 years of training and leadership experience in promoting a culture of compliance and best in class claims management practices
• Keen eye for detail to ensure all aspects of compliance are thoroughly examined and addressed.  Strong desire to ask questions, seek feedback, and understand new concepts related to compliance and claims management. Advanced problem solving skills, to be able to manage complex situations with multiple layers, and resolve to solution anticipating needs now and into the future.  Proficient in gathering and analyzing information to determine the